11.macroeconomics and health the way forward in the who african region

Journal of Biology, Agriculture and Healthcare www.iiste.org
ISSN 2224-3208 (Paper) ISSN 2225-093X (Online)
Vol 1, No.3, 2011

Macroeconomics and Health: The Way Forward in the WHO
African Region
Joses Muthuri Kirigia
World Health Organization, Regional Office for Africa, B.P. 06, Brazzaville, Congo

* E-mail of the corresponding author: kirigiaj@afro.who.int

Abstract

The specific objectives of this paper were: (i) to estimate the effects of life expectancy and mortality rates
on the per capita gross national income; and (ii) to propose to countries in the African region a set of
generic steps for implementing the action agenda recommended by WHO Commission for
Macroeconomics and Health (CMH), within the context of national development plans and poverty
reduction strategies. Four simple double-log (log-linear or constant elasticity) regression equations were
estimated with data from the World Health Statistics 2011. The dependent variable in all equations was the
logarithm of per capita gross national income.

The key findings were as follows: in equation 1 the coefficients for life expectancy and adult literacy had a
positive sign and were statistically significant at 95% confidence level; in equation 2 the coefficient for
under 5 mortality rate took a negative sign and was statistically significant; in equation 3 the coefficients
for adult mortality rate and adult literacy were statistically significant and had expected signs; and in
equation 4 the coefficient for maternal mortality was not statistically significant at 95% level of confidence
but had a negative sign as expected. These results clearly show a significant correlation between per capita
gross national income and life expectancy, under 5 mortality rate, and adult mortality rate. This implies that
by working closely with health development partners, countries in the African region can better their
economic prospects through greater investments in close-to-client health systems and increased use of
proven cost-effective prevention and treatment interventions to curb mortality and increase life expectancy.
Keywords: Macroeconomics, Health, African Region, Way Forward

1. Introduction

Improved health is not just an end in itself but also an essential means of reducing poverty and achieving
sustained economic growth. In the WHO African Region, health outcomes must be significantly improved
because the current huge burden of disease largely undermines socioeconomic development.

In recognition of the above, the WHO Director-General established the Commission on Macroeconomics
and Health (CMH) in January 2000 to study the links between increased investments in health, economic
development and poverty reduction. The findings of the Commission, published in December 2001 (WHO
2001), demonstrated that judicious investments in health can help increase economic growth in developing
countries.

The Commission’s analysis revealed that:
• ill-health contributes significantly to poverty and low economic growth;
• a few health conditions account for the high proportion of ill-health and premature deaths;
• a substantial increase in the use of cost-effective interventions in addressing priority health
problems can potentially save millions of lives per year;
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• a close-to-client (CTC) system is required to increase cost-effective interventions targeting the
poor;
• the current level of health spending in Member States is not sufficient to help implement
cost-effective interventions.

The Fifty-fifth World Health Assembly, held in May 2002, commended the CMH action agenda as a useful
approach to the achievement of the Millennium Development Goals (MDGs) (WHO 2002, UN 2000) and
the targets of the New Partnership for Africa’s Development (NEPAD) (NEPAD 2001).

The purpose of this paper is to put the key CMH findings in the WHO African Region perspective. The
specific objectives are: (i) to estimate the effects of life expectancy and mortality rates on the per capita
gross national income (GNI); and (ii) to propose to countries in the African region a set of generic steps for
implementing the action agenda recommended by WHO Commission for Macroeconomics and Health
(CMH), within the context of national development plans and poverty reduction strategies.

2. Methods
2.1 Analytical framework

According to the CMH, per capita gross national income is hypothesized to be a function of health
outcomes (e.g. life expectancy and mortality rates) and education (e.g. adult literacy) (WHO 2001). We
would expect a positive relationship between per capita GNI and life expectancy and educational
attainment. As life expectancy and adult literacy increase, we would expect per capita GNI to also increase
(and vice versa). On the contrary, we would expect an inverse relationship between per capita GNI and
mortality rates. This is because while increases in life expectancy and adult literacy enhance stocks of
human capital, and hence productive capabilities, premature mortality erodes them.

Formally, the effect of life expectancy and mortality rates on the per capita GNI can be expressed as
follows:

PER_CAPITA_GNI = f (LE, U5MR,1560MR, MMR, Literacy)...........(1)
where: f = function of; PER_CAPITA_GNI = per capita GNI in purchasing power parity, i.e. total
gross national income divided by population; LE = average life expectancy at birth (years); U5MR =
under-five mortality rate (probability of dying by age 5 per 1000 live births); 1560MR = adult
mortality rate (probability of dying between 15 and 60 years per 1000 population); MMR = maternal
mortality ratio (per 100 000 live births); Literacy = adult literacy rate (%).

We estimated four simple double-log equations specified below:

logPER_CAPITA_GNI = log α + β1 log LE + β 2 log Literacy + ε .........................(2)

logPER_CAPITA_GNI = log α + β1 log U 5MR + β 2 log Literacy + ε ...................(3)

logPER_CAPITA_GNI = log α + β1 log 1560MR + β 2 log Literacy + ε .............( 4)

logPER_CAPITA_GNI = log α + β1 log MMR + β 2 log Literacy + ε .......... ...(5)
where: log is the natural log (i.e., log to the base e, where is e equals 2.718); a is the intercept term; β’s

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are the coefficients of elasticity (CoE), i.e. the percentage change in per capita GNI for a given small
percentage change in a specific explanatory variable; and ε is a random (stochastic) error term
capturing all factors that affect per capita GNI but are not taken into account explicitly (Gujarati 1988,
Kirigia et al 2004).

CoE is the ratio of the percentage change in per capita GNI (PER_CAPITA_GNI) to the percentage
change in a specific independent (explanatory) variable, such as LE. Mathematically, the absolute
value of the CoE ranges from zero (perfectly inelastic PER_CAPITA_GNI) to infinity (perfectly
elastic PER_CAPITA_GNI). Unitary elastic PER_CAPITA_GNI depicts a scenario in which the
percentage change in PER_CAPITA_GNI is exactly equal to the percentage change in an independent
variable, i.e. CoE=1. Inelastic PER_CAPITA_GNI refers to a situation where PER_CAPITA_GNI is
relatively unresponsive to a change in an independent variable, i.e. CoE > 0 < 1. Similarly, elastic
PER_CAPITA_GNI implies that GNI is relatively responsive to a change in an independent variable,
i.e. CoE > 1. Thus, in simple terms, elasticity is a measure of the degree of responsiveness of a
dependent variable (PER_CAPITA_GNI in our case) to changes in an independent variable, such as
LE.

2.2 Data Sources and Analysis

The per capita GNI, average life expectancy, under-five mortality rate, adult mortality rate, maternal
mortality rate, and adult literacy rate data on the 46 countries in the WHO African Region, which was used
to estimate equations 2 to 5, were obtained from the World Health Statistics 2011 (WHO 2011). The raw
data were collated in EXCEL spreadsheet, and subsequently, exported to STATA (Statacorp 2010) for
analysis. Prior to estimation of the regression equation 2 to 5, both the dependent and independent
(explanatory) variables were transformed into their logarithms using standard STATA commands.

3. Results and Discussion
3.1 Analysis

Table 1 provides a summary of descriptive Statistics (mean, median, standard deviation, minimum,
maximum). There is remarkable variation in per capita GNI between countries, e.g. the minimum is Int$163
while the maximum is Int$19,330 (in PPP). Also there is significant variation in the life expectancies and
mortality rates between countries – minimum is 47 years and maximum is 73 years.

Table 2 presents the results of regression of logarithm of per capita GNI against various health outcomes
(explanatory variables). In equation 1, the coefficients for the logarithms of average life expectancy at birth
and adult literacy were positive and statistically significant at 95% level of confidence. The per capita GNI
was elastic with respect to both explanatory variables since their coefficients were greater than one. As
shown in Table 2, the life expectancy elasticity coefficient is 2.732, implying that for a one percent increase
in the life expectancy, the per capita gross national income on the average increases by about 2.732 percent.
The adjusted R-squared was 0.268, meaning that the two independent variables explained about 27% of the
total variations in the per capita GNI.

In equation 2, the coefficient for under-five mortality rate was statistically significant and had as expected a
negative sign. The coefficient for adult literacy rate had as expected a positive sign but was not significant
at 95% confidence level. Both coefficients were less than one, signifying that in this equation, the per capita
GNI was inelastic in relation to under-five mortality and adult literacy. The adjusted R-squared was 0.298,
implying that under-five mortality rate and adult literacy rate accounted for about 30% of variations in per
capita GNI.

In equation 3, the coefficients for adult mortality rate and adult literacy were both statistically significant at
95% level of confidence. The coefficient for adult mortality had a negative sign and that of adult literacy
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rate was positive as expected. Whilst the coefficient for adult mortality was less than one, the one for adult
literacy was greater than one. The adult mortality rate elasticity coefficient was -0.793, denoting that for a
one percent increase in adult mortality rate, the per capita gross national income on average decreases by
about 0.793%. Since the adult mortality rate elasticity value of 0.793 is less than one in absolute terms, one
can say that the per capita GNI is adult mortality rate-inelastic. On the contrary, since the adult education
rate elasticity value of 1.383 is greater than one in absolute terms, we can say that per capita GNI is adult
literacy-elastic. The adjusted R-squared was 0.257, indicating the two variables explained almost 26% of
variations in the dependent variable.

In equation 4, the coefficient for maternal mortality ratio was not statistically significant at 95% confidence.
However, it had a negative sign as expected. The maternal mortality elasticity coefficient of -0.062 indicate
that for a one percent increase in MMR, the per capita GNI on average decreases by about 0.062%. Because
the MMR elasticity value of 0.062 is less than one in absolute terms, one can conclude that the per capita
GNI is maternal mortality-inelastic. On the other hand, the coefficient for adult literacy rate was statistically
significant and had a positive sign, and was greater than one meaning that per capita GNI is adult
literacy-elastic in equation 4. In view of the fact that the adult literacy elasticity coefficient is 1.20, the per
capita GNI on average increases by about 1.2% for a one percent increase in the adult literacy rate. The
adjusted R-squared was 0.213, which suggests that the two variables accounted for 21% of variations in the
per capita GNI.

Figures 1 and 5 show that as the life expectancy and adult literacy rate increase, the per capita GNI also
increases. Figure 2 and 3 and 4 portray that per capita GNI decreases with increase in under-five mortality
rate, adult mortality rate, and maternal mortality ratio. These results clearly show that there is a strong
correlation between capita GNI and life expectancy, under-five mortality rate and adult mortality rate. The
findings are consistent with those of the CMH (WHO 2001), Gallup and Sachs (2001) and Bloom and
Sachs (1998) among others.

The WHO African Region population suffers a heavy burden of communicable and non-communicable
diseases. In the year 2002, 66% of the 10.7 million deaths that occurred in the Region resulted from the ten
causes shown in Figure 7 (WHO 2005a). HIV/AIDS, lower respiratory tract infection, malaria, diarrhoeal
diseases and maternal and perinatal conditions alone accounted for 55% of the deaths and 54% of
disability-adjusted life years. This heavy burden of disease and its multiple effects on productivity,
demography and education have contributed significantly to Africa’s chronically poor economic
performance (Bloom and Sachs 1998).

Substantial increase in the use of available cost-effective interventions to address priority health problems
can potentially save millions of lives each year in the Region. About 47% of the population in the Region
have no access to health services and more than 70% of the people have no access to essential drugs (WHO
2000); and about 59% of pregnant women deliver babies without the assistance of skilled health personnel;
out-of-pocket expenditures constitute 51% to 90% of the private health expenditure in 14 countries and
91% to 100% in 24 countries (in a region where 38.2% of people live below the international income
poverty lines of US$1 per day) (WHO 2005a). Many cost-effective interventions (e.g. use of
insecticide-treated materials, directly-observed treatment - short-course (DOTS), condoms, vaccines against
childhood killer diseases) are available and yet they are not reaching the poor (WHO 2001). There is,
therefore, need to substantially increase the use of such interventions.

A close-to-client (CTC) system (a health system that provides affordable promotive, preventive and basic
curative care in localities inhabited mainly by the poor) is required to scale up cost-effective public health
interventions targeting the poor (WHO 2001). CTC systems consisting of health centres, health posts and
outreach points are capable of delivering the key cost-effective interventions (cost-effective interventions
are public health interventions with the least cost per unit of effectiveness) required to reduce the burden of
disease and improve health conditions in the Region. Developing an effective CTC system requires
increased investments in infrastructure and health personnel capacity building.
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Opportunities exist to improve current resource allocation within health systems by increasing the
proportion of resources allocated to CTC systems. By undertaking significant health sector reforms, more
resources can be reallocated from over-resourced, less cost-effective systems of care to more cost-effective
CTC systems. There is also growing evidence in the Region that national health systems (Kirigia et al
2007), hospitals (Mbeeli et al 2004; Osei et al 2005; Kirigia, Emrouznejad and Sambo 2002; Masiye et al
2002; Zere, McIntyre and Addison 2001; Kirigia, Lambo and Sambo 2000) and health centers (Kirigia et al
2008; Masiye et al 2006; Renner et al 2005; Kirigia et al 2004; Kirigia, Sambo and Scheel 2001) can attend
to more patients if the resources available to them are better managed.

Despite efforts to improve efficiency in the use of available resources, the level of health spending in
Member States is not sufficient to scale up cost-effective interventions. The CMH estimated that a
minimum of US$ 34 per capita per year would be required to provide an essential package of public health
interventions (WHO 2001). Between 2000 and 2008 the number of countries achieving the CMH
recommendation increased from 11 to 27, out of 46 African Regional countries (WHO 2011). Thus, the 19
(41%) countries currently spending less than US$ 34 on health per capita per year will need to increase
their budgetary allocations to reach the recommended minimum health spending.

Member States can increase their domestic resource allocations to health. Heads of State of African
countries made a commitment in Abuja to allocate at least 15% of their annual budgets to the health sector
(OAU 2000). Yet, in 2008, six countries spent less than 5% of their total annual national budget on health;
14 countries spent between 5% and 9%; 18 countries spent between 10% and 14%; and seven countries
spent 15% and above of their budget on health. Only seven countries spent 15% or above of their budgets
on health (WHO 2011). This means that 39 countries spent less than 15% of their national budgets on
health and will need to take appropriate steps to fulfill the commitment given by their respective Heads of
State (See Figure 8).

In spite of the increased allocation of domestic resources to health, a financing gap will still need to be
filled from external sources. CMH estimated that, globally, US$ 27 billion per year (as measured against
the current US$ 6 billion) will need to be mobilized from international donors to complement domestic
resources (WHO 2001). Therefore, Member States need to advocate, individually and collectively, at the
international level, for a fair share of such funds. In addition, there will be need to significantly improve the
management of resources and the capacity to use the additional resources in a manner that especially
benefits the poor.

Investment in health-related sectors ought to be increased to tackle social determinants of health (WHO
2008). Almost 66% of the population in the Region lack sustainable access to improved sanitation facilities;
39% lack sustainable access to an improved water source; and 37% of adults in the Region are illiterate
(WHO 2011). This underscores the need for increased investments in sectors such as water, sanitation,
education and agriculture, all of which have an impact on health in order to achieve the relevant MDGs.

3.2 Regional Response to the Report of the Commission on Macroeconomics and Health

In June 2002, a Regional Health Economics Capacity Strengthening Workshop took place in Windhoek,
Namibia. A total of 103 senior economists, planners and public health specialists from 43 countries
participated in the workshop which critically examined the CMH findings and recommendations; the health
component of Poverty Reduction Strategy Papers (PRSPs); health care financing; national health accounts;
and health systems performance assessment.

The participants generally felt that the CMH report presented compelling evidence that health was a
prerequisite for economic development, and that the recommended action agenda was pertinent for the
African Region. However, they envisaged that countries planning to implement that agenda might face the
following challenges:
a) limited capacity of ministries of health to undertake advocacy and negotiate with other sectors and
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partners;
b) weak national health management information systems;
c) need to revise the health component of PRSPs to include strategies for scaling up the essential
package of interventions;
d) proliferation of committees at the national level;
e) attrition of human resources resulting from brain drain;
f) lack of sustainable health care financing mechanisms;
g) making health systems responsive to the needs and expectations of the poor;
h) coordination of donor support to enhance contributions to the attainment of national health
developmental goals.

At the recommendation of the Windhoek workshop, an agenda item entitled “Macroeconomics and health:
The way forward in the African Region”, was included in the Fifty-third session of the WHO Regional
Committee for Africa. The Committee adopted a resolution (WHO Regional Office for Africa 2003) urging
Member States of the African Region:
a) to widely disseminate among all stakeholders the findings and recommendations of the CMH and
build consensus for action;
b) to establish or strengthen institutional mechanisms for implementing the recommendations of the
CMH;
c) to develop multi-year strategic plans for scaling up health investment into pro-poor health
interventions;
d) to revise health sector and health-related development plans, the relevant components of Poverty
Reduction Strategy Papers (PRSPs) and Medium-Term Expenditure Frameworks (MTEFs) to
incorporate strategic plans for scaling up pro-poor health investments;
e) to fulfill the pledge made by Heads of State in Abuja to allocate at least 15% of their annual
budgets to the improvement of the health sector;
f) to utilize the multi-year strategic plans to mobilize resources from domestic and external sources
in a sustainable manner;
g) to closely involve relevant ministries and agencies with responsibility for specific components of
the strategic plan (e.g. health services, water, sanitation, nutrition, education, finance, planning)
during planning, implementation and monitoring;
h) to strengthen health economics and public health capacity within the ministries of health and other
relevant sectors in order to enhance health investments, and pre-empt and mitigate negative effects
of development projects on public health.

3.3 The Way Forward

The CMH report recommends enhanced political commitment, at both national and international levels, to
increased investments for scaling up the delivery of essential health interventions using close-to-client
health systems (WHO 2001). Given that different Member States face different challenges, and considering
the lessons learnt from the Ghana (Government of Ghana 2005) experience, this paper suggests steps that
can be taken to implement the CMH recommendations. The steps suggested below should be implemented
within the framework of:
a) existing national policies, development plans and poverty reduction strategies;
b) administrative, planning, implementation and monitoring structures and processes existing in
individual countries.

The suggested steps to be taken at the country level are as follows:

Step 1: Dissemination, at country level, of the findings and recommendations of the Commission on
Macroeconomics and Health and consensus building on their relevance

Ministries of health, with support from relevant United Nations (UN) Agencies and the World Bank, may
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organize a meeting of key stakeholders to disseminate the CMH findings and recommendations and build
consensus on their relevance to the national health situation. This would potentially set in motion a process
that would build greater political and financial commitment to the health sector.

Step 2: Making institutional arrangements to facilitate implementation of the recommendations of the
Commission on Macroeconomics and Health in the countries

Individual countries may set up an inter-ministerial national steering committee on macroeconomics and
health or, where appropriate, expand the terms of reference and composition of existing committees
performing similar functions to take action on the CMH recommendations. This committee may spearhead
the scaling up of priority health and health-related interventions and, at national and international levels,
undertake advocacy for increased investments in health. Its membership may consist of ministers
responsible for health, economic planning and regional cooperation, finance, local government and rural
development, works and housing as well as parliamentarians, representatives of civil society, the private
sector, UN agencies, and bilateral and multilateral donors.

A technical committee, acting as the secretariat of the national steering committee on macroeconomics and
health, may be established to undertake a health situation analysis and an economic analysis of alternative
health interventions and financing options. This committee may comprise a health economist,
representatives of ministries of health (including public health specialists and planners); education; water
supply and sanitation; finance; economic planning and regional cooperation; local government and rural
development; as well as representatives of the donor community and relevant UN Agencies.

Step 3: Analysis and strategy development

Drawing on the recommendations of CMH and national strategic plans such as the Poverty Reduction
Strategy Papers, the technical committee will carry out analyses of: the national health situation; national
health policies, including human resource policies and plans; health system performance (goals and
functions); national health accounts (or national health expenditure) to quantify the financial contribution to
health from the activities undertaken by all the sectors; and macroeconomic (including poverty) indicators
to facilitate the development of a sound strategy for scaling up health interventions. The emerging gaps in
information and health systems performance can be addressed in a multi-year strategic plan. The main
purpose of this plan is to extend the coverage of essential health and health-related services after taking into
account synergy with other health-related sectors. It should ensure consistency with sound macroeconomic
policy framework and provide the basis for filling information gaps through adequate investment in
operations research.

The plan would contain:
(a) an analysis of health and health-related sectors;
(b) a set of priority national health problems;
(c) a package of cost-effective essential public health interventions for addressing problems;
(d) current levels of coverage of various essential interventions;
(e) the target coverage of individual essential health interventions;
(f) the cost of scaling up the use of essential interventions to the desired levels including the cost of
strengthening close-to-client health services;
(g) an estimate of the current level of spending (broken down by source) on essential interventions;
(h) an estimate of the expenditure gap (i.e. item “f” minus item “g” above);
(i) an indication of how the expenditure gap would be financed (from domestic and international
sources);
(j) a monitoring and evaluation section.
The relevant ministries and agencies primarily responsible for specific components of the defined essential
public health interventions will need to devise proposals for scaling up such interventions.

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Step 4: Filling expenditure gaps

The technical committee will, on the recommendation of the national steering committee, develop scenarios
of how expenditure gaps can be bridged. The advantages and disadvantages of each scenario should be
carefully examined and considered. The scenarios may include: reduction of the technical and allocative
inefficiencies within and between health-related sectors and subsectors; termination of least cost-effective
diagnostic procedures and health interventions; national social health insurance (Carrin, Desmet and Basaza
2001; WHO 2005b; African Union 2006) funded from “sin” taxes (e.g. on tobacco and alcohol); a
dedicated tax for health; reallocation of budgetary resources from other sectors such as defence; reduction
of subsidies for the export-oriented manufacturing industry; funds expected from the highly-indebted poor
countries (HIPC) initiative; soft loans and grants from multilateral and bilateral donor agencies;
development of project proposals for submission to the Global Alliance for Vaccines and Immunizations
(GAVI), the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and the Multicountry AIDS
Programme of the World Bank.

Step 5: Using the multi-year strategic plan (step 3) to revise the health and health-related sector
development plans and the relevant components of PRSPs

The multi-year strategic plan should be incorporated into the relevant health and health-related sector
development plans (e.g. health, water supply and sanitation, education) and the relevant components of
poverty reduction strategy papers (PRSPs) and the Medium Term Expenditure Frameworks (MTEF).

Step 6: Implementation of the multi-year strategic plan

The ministries and agencies with primary responsibility for specific components of the strategic plan (e.g.
health services, water, sanitation, nutrition) will scale up their respective interventions.

Step 7: Monitoring, evaluation and reporting

The national steering committee on macroeconomics and health will monitor the implementation of the
strategic plan as well as the proposals developed by each lead ministry or agency. To that end, the national
steering committee will develop key indicators and decide on a frequency of reporting consistent with the
national reporting mechanisms. As a guide, the national steering committee may consider meeting
half-yearly to review progress in the implementation of the strategic plan and its relevant proposals. The
lessons emerging from these reviews will then be used to revise the plans.

Partner alliances ought to be built and maintained at all levels, to ensure that countries receive appropriate
support when developing, implementing, monitoring and evaluating multi-year plans for scaling up
pro-poor health investments. Such alliances would involve stakeholders such as the relevant UN and
bilateral development agencies, the World Bank, the African Development Bank, the African Union, the
NEPAD Secretariat, civil society, international and national NGOs, private organizations, academics and
global initiatives, e.g. GFATM, GAVI, Stop TB, Roll Back Malaria Partnership.

Those partners ought to:
(a) disseminate the key CMH findings and recommendations to governments, members of parliament,
civil servants, civil society, local leaders and other relevant development partners;
(b) support countries to develop or strengthen existing national institutional mechanisms for planning,
implementing and monitoring the CMH recommendations;
(c) provide technical support to the national steering committee and lead ministries or agencies to
enable them to develop plans and proposals for scaling up relevant national interventions;
(d) strengthen Member States’ capacity to collect, analyze, document, disseminate and utilize relevant
health and economic evidence;
(e) monitor and document lessons emerging from the implementation of the CMH recommendations

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in different countries and facilitate shared learning among countries.

5. Conclusion

This paper has attempted to put the key findings of the CMH within the context of the African Region. It
has proposed to countries in the African Region a set of generic steps for implementing the action agenda
recommended by CMH, within the context of national development plans and poverty reduction strategies.

By working closely with health development partners, countries can better their economic prospects
through greater investments in close-to-client health systems and increased use of cost-effective
interventions in addressing priority national health problems.

Acknowledgement

We are grateful to Ministers of Health from the 46 countries of the WHO African Region and delegates for
their comments on an earlier version of this paper during the 53rd session of the WHO Regional Committee
for Africa. I also do appreciate the comments and suggestions made by the WHO/AFRO technical staff who
peer reviewed an earlier version of this paper. Mrs Eva Ndavu provided excellent editorial support. I owe
profound gratitude to Jehovah Jireh for the inspiration and for assuring sustenance in the process of
preparing the paper.

This paper contains the views of the author only and does not represent the decisions or stated policies of
the World Health Organization.

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Vol 1, No.3, 2011
4.5
Logarithm of per capita gross national income
2.5 3 3.5
2 4

1.65 1.7 1.75 1.8 1.85
Logarithm of life expectancy in years

Figure 1: Per capita gross national income versus life expectancy for males

18

Vol 1, No.3, 2011
4.5
2.5 3 3.5
2 4

1 1.5 2 2.5
Under-five mortality rate

Figure 2: Per capita gross national income versus under-five mortality rate

19

Vol 1, No.3, 2011
4.5
2.5 3 3.5
2 4

2 2.2 2.4 2.6 2.8
Logarithm of adult mortality rate

Figure 3: Per capita income versus adult mortality rate

20

Vol 1, No.3, 2011
4.5
2.5 3 3.5
2 4

-6 -4 -2 0 2 4
logarithm of maternal mortality ratio

Figure 4: Per capita income versus maternal mortality ratio

21

Vol 1, No.3, 2011
4.5
2.5 3 3.5
2 4

1.4 1.6 1.8 2
Logarithm of adult literacy rate

Figure 5: Per capita income versus adult literacy rate

22

Vol 1, No.3, 2011

Figure 6: Leading causes of death in the WHO African Region, 2002

23

Vol 1, No.3, 2011

Zambia
Tanzania
Uganda
Togo
Swaziland
South Africa
Sierra Leone
Seychelles
Senegal
Sao Tome and Principe
Rwanda
Nigeria
Niger
Namibia
Mozambique
Mauritius
Mauritania
Mali
Malawi
Madagascar
Liberia
Lesotho
Kenya
Guinea-Bissau
Guinea
Ghana
Gambia
Gabon
Ethiopia
Eritrea
Equatorial Guinea
DRC
Côte d'Ivoire
Congo
Comoros
Chad
Central African Republic
Cape Verde
Cameroon
Burundi
Burkina Faso
Botswana
Benin
Angola
Algeria

0 2 4 6 8 10 12 14 16 18 20
Percent

Year 2000 Year 2008

Figure 7: General government expenditure on health as % of total government expenditure

24

Vol 1, No.3, 2011

Table 1: Descriptive Statistics (mean, median, standard deviation, minimum, maximum)
Variable Mean Median Standard Minimum Maximum
deviation
Per capita 2,632 1,510 4,640 163 19,330
gross national
income
life expectancy 54 55 7 47 73
Under-five 127 111 51 10 209
mortality rate
Adult (15-60 383 364 125 120 613
years)
mortality rate
Maternal 620 490 284 36 1,200
mortality ratio
Logarithm of 63 70 20 26 93
adult literacy
rate

25

Vol 1, No.3, 2011

Table 2: Regression of logarithm of per capita gross national income against various health outcome
indicators
Equation Variable Coefficient ‘t’ statistic P > |t| 95% confidence interval
1 Logarithm of life 2.732117 2.40 0.021 .4331116 5.031122
expectancy at birth
Logarithm of adult 1.136843 2.80 0.008 .3183335 1.955352
literacy rate
Constant -3.551565 -1.84 0.073 -7.444182 .3410521
Number of 46
observations
F( 2, 43) 9.24
Adjusted R-squared 0.2680
2 Logarithm of -.6861078 -2.80 0.008 -1.180436 -.1917794
under-five
mortality rate
Logarithm of adult .7308112 1.62 0.112 -.178284 1.639906
literacy rate
Constant 3.308904 2.89 0.006 1.001472 5.61633
Number of 46
observations
F( 2, 43) 10.56
3 Logarithm of adult -.7934807 -2.24 0.030 -1.507957 -.0790047
(15-60 years)
mortality rate
Logarithm of adult 1.38352 3.51 0.001 .5885413 2.178499
literacy rate
Constant 2.782053 2.42 0.020 .4617483 5.102358
Number of 46
observations
F( 2, 43) 8.78
4 Logarithm of -.0618062 -1.53 0.132 -.1430848 .0194724
maternal mortality
ratio
Logarithm of adult 1.201144 2.83 0.007 .3440617
literacy rate 2.058226
Constant 1.248408 1.56 0.125 -.3620744 2.8588
Number of 46
observations
F( 2, 43) 7.10

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